August 7, 2019

Drug-related problems in older people after hospital discharge and interventions to reduce them

Drug-related problems in older people during care transitions have become a major public health problem since they threaten patient safety. The objective of our paper is to investigate the extent and frequency of drug-related problems (discontinuity, adherence, errors, interactions and adverse events) after hospital discharge and the efficacy of interventions […]
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Drug-related problems in older people during care transitions have become a major public health problem since they threaten patient safety. The objective of our paper is to investigate the extent and frequency of drug-related problems (discontinuity, adherence, errors, interactions and adverse events) after hospital discharge and the efficacy of interventions intended to reduce them. We included 20 studies in the review. All of them underlined the high frequency and complexity of drug-related problems in older people after hospital discharge. Interventions proposed to improve care transitions led to diverse and sometimes contradictory results, but the findings suggested that combining hospital discharge measures with home follow-up strategies is of value. We conclude that it is not possible to estimate the frequency of drug-related problem through a review of selected articles or to evaluate the efficacy of the proposed interventions. More research is needed in this field to reduce uncertainty and generate evidence-based recommendations for physicians.
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http://psnet.ahrq.gov/resource.aspx?resourceID=18322

August 7, 2019

Coordinating Care — A Perilous Journey through the Health Care System (Thomas Bodenheimer, M.D. N Engl J Med 2008; 358:1064-1071March 6, 2008)

In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care provi ders. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care […]
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In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care provi ders. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year.2 Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.
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http://www.nejm.org/doi/full/10.1056/NEJMhpr0706165

August 8, 2019

The Evaluation of the Medicare Coordinated Care Demonstration Findings for the First Two Years

Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing […]
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Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing on program impacts over the first year after enrollment for beneficiaries who enrolled during the first year, and over the first 25 months of operations for all enrollees. Findings presented include program-specific estimates of impacts on (1) survey-based measures of patients. health status, knowledge, behavior, satisfaction with their health care, quality of care, and quality of life; and (2) claims-based measures of patients. Medicare service use and expenditures, and the quality of care received. The report links differences across programs in these impacts to differences in the interventions and the target populations in order to draw inferences about .what works. and .for whom.. This synthesis of findings draws on an earlier report to Congress that described the types of programs and beneficiaries participating in the demonstrations, the interventions the programs have implemented, and how well patients and physicians like the programs (Brown et al. 2004). This report updates that information and adds analyses of Medicare service use and expenditures and a scoring methodology developed specifically for this evaluation to rate the quality of each program’s intervention on several dimensions. The findings in brief indicate that patients and physicians were generally very satisfied with the program, but few programs had statistically detectable effects on patients. behavior or use of Medicare services. Treating only statistically significant treatment-control differences as evidence of program effects, the results show: • Few effects on beneficiaries. overall satisfaction with care • An increase in the percentage of beneficiaries reporting they received health education • No clear effects on patients. adherence or self-care • Favorable effects for only two programs each on: the quality of preventive care, the number of preventable hospitalizations, and patients. well-being • A small but statistically significant reduction (about 2 percentage points) across all programs combined in the proportion of patients hospitalized during the year after enrollment • Reduced number of hospitalizations for only 1 of the 15 programs over the first 25 months of program operations • No reduction in expenditures for Medicare Part A and B services for any program
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http://www.mathematica-mpr.com/publications/pdfs/mccdfirsttwoyrs.pdf

August 8, 2019

Improving Transitions to Reduce Readmissions

Bisognano M, Boutwell A. Frontiers of Health Services Management. 25(3):3-10.2009. http://www.ihi.org/resources/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx. Accessed 8/13/14. Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, corrdination between providers and between settings is to often not conducted as a team effort.
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Bisognano M, Boutwell A. Frontiers of Health Services Management. 25(3):3-10.2009. http://www.ihi.org/resources/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx. Accessed 8/13/14. Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, corrdination between providers and between settings is to often not conducted as a team effort.
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http://www.ihi.org/knowledge/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx

August 8, 2019

Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. Aurora Healthcare, Milwaukee Wisconsin

Agency for Healthcare Research and Quality. Aurora Health Care. http://www.innovations.ahrq.gov/content.aspx?id=1766. Accessed 4/16/13. Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. A community-wide medication reconciliation collaborative, involving health care consumers, providers, pharmacists, and community stakeholders, gave elderly patients and their providers the tools and education […]
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Agency for Healthcare Research and Quality. Aurora Health Care. http://www.innovations.ahrq.gov/content.aspx?id=1766. Accessed 4/16/13. Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. A community-wide medication reconciliation collaborative, involving health care consumers, providers, pharmacists, and community stakeholders, gave elderly patients and their providers the tools and education needed to assemble and verify accurate medication lists and communicate effectively to prevent medication errors. As a result, the rate of accurate medication lists among targeted patients improved from 55 percent to 72 percent. Evidence Rating Moderate: The evidence consists primarily of before and after comparisons of the accuracy of medication lists and comparison with controls, which included Aurora practices in which there was no intervention and post-implementation surveys eliciting patient and provider views. Although the project provided extensive education and support and employed controls, a direct causal link between the program and the improved accuracy rates cannot be confirmed, as confounding variables may have influenced the results, including recent emphasis and education by professional organizations.
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http://www.innovations.ahrq.gov/content.aspx?id=1766

August 8, 2019

Medication Reconciliation Form: Baptist Hospital

Baptist Memorial Hospital. Medication Reconciliation Form. Http://www.ihi.org/resources/Pages/Tools/BMHMemphisMedicationReconciliationForm.aspx. Published May 2005. Accessed 7/9/14. As a participant in the Institute for Healthcare Improvement’s Reducing High Hazard Adverse Drug Events Breakthrough Series Collaborative, the Baptist Memorial Hospital, Memphis campus has tested this tool on a pilot population to decrease their rate of unreconciled […]
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Baptist Memorial Hospital. Medication Reconciliation Form. Http://www.ihi.org/resources/Pages/Tools/BMHMemphisMedicationReconciliationForm.aspx. Published May 2005. Accessed 7/9/14. As a participant in the Institute for Healthcare Improvement’s Reducing High Hazard Adverse Drug Events Breakthrough Series Collaborative, the Baptist Memorial Hospital, Memphis campus has tested this tool on a pilot population to decrease their rate of unreconciled medications in order to improve patient safety.
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http://www.ihi.org/knowledge/Pages/Tools/BMHMemphisMedicationReconciliationForm.aspx

August 8, 2019

Institute for Healthcare Improvement

The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for […]
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The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
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http://www.ihi.org

August 8, 2019

UMassMemorial Preadmission Medications List verification and Order Form (Medication Reconciliation)

UMass Memorial Medical Center. Preadmission Medication List Verification and Order Form (Medication Reconciliation). Http://www.macoalition.org/Initiatives/RecMeds/UMassReconcilForm.doc. Accessed 7/9/14. This form/process has been introduced to facilitate providers getting patients on the most accurate list of medications at admission, transfer, and discharge—the times when medication errors are most likely to occur. Careful attention to […]
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UMass Memorial Medical Center. Preadmission Medication List Verification and Order Form (Medication Reconciliation). Http://www.macoalition.org/Initiatives/RecMeds/UMassReconcilForm.doc. Accessed 7/9/14. This form/process has been introduced to facilitate providers getting patients on the most accurate list of medications at admission, transfer, and discharge—the times when medication errors are most likely to occur. Careful attention to this process has been shown to result in fewer errors and reduction in harm to patients.
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http://www.macoalition.org/Initiatives/RecMeds/UMassReconcilForm.doc

August 8, 2019

Aurora Health Care: How to create an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach

Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the […]
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Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the needs of our patients.
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http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf

August 8, 2019

Care Transitions Measure (CTM-3 and CTM-15)

Coleman, E. The CTM-3 and CTM-15. The Care Transitions Program. Http://www.caretransitions.org/ctm_main.asp. Accessed 7/9/14. We have created two versions of the CTM®. The CTM-15® is a comprehensive version designed for those programs that focus explicitly on measuring care transitions. Alternatively, the CTM-3® is a more concise measure (and a subset of […]
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Coleman, E. The CTM-3 and CTM-15. The Care Transitions Program. Http://www.caretransitions.org/ctm_main.asp. Accessed 7/9/14. We have created two versions of the CTM®. The CTM-15® is a comprehensive version designed for those programs that focus explicitly on measuring care transitions. Alternatively, the CTM-3® is a more concise measure (and a subset of the CTM-15®) designed for those programs that focus on care transitions either alone or in addition to other aspects of care and can only employ a limited number of items. Both measures have been rigorously developed and have been shown to predict return to the hospital and/or emergency department and discriminate among hospitals known to differ in performance in this area. Three question patient survey.
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http://www.caretransitions.org/ctm_main.asp

August 8, 2019

NTOCC Suggested Common/Essential Data Elements for Medication Reconciliation

NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
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http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf

August 8, 2019

NTOCC Medication Reconciliation Form Applicable Across All Continuum of Care Lines

Form assists in documenting patient’s understanding of Medication at time of admission or treatment, new medication added, medication list inclusive of continued and new medications
Form assists in documenting patient's understanding of Medication at time of admission or treatment, new medication added, medication list inclusive of continued and new medications
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August 8, 2019

Pharmacist-conducted medication reconciliation in an emergency department

Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacist-conducted medication reconciliation in an emergency department. Am J Health-Syst Pharm. 2007;64(16):1720-1723.http://www.ajhp.org/content/64/16/1720.abstract. Accessed April 26, 2013. Conclusion. Pharmacist-conducted medication reconciliation in the ED increased compliance to the institution‘s medication reconciliation policy for admitted patients. Pharmacist-acquired medication histories had significantly fewer errors in […]
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Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacist-conducted medication reconciliation in an emergency department. Am J Health-Syst Pharm. 2007;64(16):1720-1723.http://www.ajhp.org/content/64/16/1720.abstract. Accessed April 26, 2013. Conclusion. Pharmacist-conducted medication reconciliation in the ED increased compliance to the institution‘s medication reconciliation policy for admitted patients. Pharmacist-acquired medication histories had significantly fewer errors in documentation and had more documentation of patient allergies.
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http://www.ajhp.org/cgi/content/abstract/64/16/1720

August 8, 2019

Caregiving and Chronic Care: The Guided Care Program for Families and Friends

Wolff JL, et al. Caregiving and Chronic Care: The Guided Care Program for Families and Friends.Gerontol A Biol Sci Med Sci.2009.64A (7): 785-791.http://biomedgerontology.oxfordjournals.org/content/64A/7/785.abstract. Accessed April 26, 2013. Background The Guided Care Program for Families and Friends (GCPFF) is one component of “Guided Care” (GC), a model of primary care for […]
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Wolff JL, et al. Caregiving and Chronic Care: The Guided Care Program for Families and Friends.Gerontol A Biol Sci Med Sci.2009.64A (7): 785-791.http://biomedgerontology.oxfordjournals.org/content/64A/7/785.abstract. Accessed April 26, 2013. Background The Guided Care Program for Families and Friends (GCPFF) is one component of “Guided Care” (GC), a model of primary care for chronically ill older adults that is facilitated by a registered nurse who has completed a supplemental educational curriculum. Methods The GCPFF melds support for family caregivers with the delivery of coordinated and comprehensive chronic care and seeks to improve the health and well-being of both patients and their family caregivers. The GCPFF encompasses (a) an initial meeting between the nurse and the patient's primary caregiver, (b) education and referral to community resources, © ongoing “coaching,” (d) a six-session group Caregiver Workshop, and € monthly Support Group meetings, all facilitated by the patient's GC nurse. Results A cluster-randomized controlled trial of GC is underway in 14 primary care physician teams. Of 904 consented patients, 450 (49.8%) identified a primary caregiver; 308 caregivers met eligibility criteria, consented to participate, and completed a baseline interview. At 6-month follow-up, intervention group caregivers’ mean Center for Epidemiological Studies Depression (CESD) and Caregiver Strain Index (CSI) scores were respectively 0.97 points (p = .14) and 1.14 points (p = .06) lower than control group caregivers’. Among caregivers who provided more than 14 hours of weekly assistance at baseline, intervention group caregivers’ mean CESD and CSI scores were respectively 1.23 points (p = .20) and 1.83 points (p = .04) lower than control group caregivers’. Conclusions The GCPFF may benefit family caregivers of chronically ill older adults. Outcomes will continue to be monitored at 18-months follow-up. BACKGROUND: The Guided Care Program for Families and Friends (GCPFF) is one component of “Guided Care” (GC), a model of primary care for chronically ill older adults that is facilitated by a registered nurse who has completed a supplemental educational curriculum. METHODS: The GCPFF melds support for family caregivers with the delivery of coordinated and comprehensive chronic care and seeks to improve the health and well-being of both patients and their family caregivers. The GCPFF encompasses (a) an initial meeting between the nurse and the patient's primary caregiver, (b) education and referral to community resources, (c) ongoing “coaching,” (d) a six-session group Caregiver Workshop, and (e) monthly Support Group meetings, all facilitated by the patient's GC nurse. RESULTS: A cluster-randomized controlled trial of GC is underway in 14 primary care physician teams. Of 904 consented patients, 450 (49.8%) identified a primary caregiver; 308 caregivers met eligibility criteria, consented to participate, and completed a baseline interview. At 6-month follow-up, intervention group caregivers’ mean Center for Epidemiological Studies Depression (CESD) and Caregiver Strain Index (CSI) scores were respectively 0.97 points (p = .14) and 1.14 points (p = .06) lower than control group caregivers’. Among caregivers who provided more than 14 hours of weekly assistance at baseline, intervention group caregivers’ mean CESD and CSI scores were respectively 1.23 points (p = .20) and 1.83 points (p = .04) lower than control group caregivers’. CONCLUSIONS: The GCPFF may benefit family caregivers of chronically ill older adults. Outcomes will continue to be monitored at 18-months follow-up.
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http://biomedgerontology.oxfordjournals.org/content/64A/7/785.abstract

August 8, 2019

Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2

American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2. http://www.accp.com/docs/positions/misc/CoreElements.pdf. 2008. Accessed April 26, 2013. Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM) in July […]
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American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2. http://www.accp.com/docs/positions/misc/CoreElements.pdf. 2008. Accessed April 26, 2013. Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM) in July 2004 (Appendix A). Building on the consensus definition, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation developed a model framework for implementing effective MTM services in a community pharmacy setting by publishing Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Version 1.0. The original version 1.0 document described the foundational or core elements of MTM services that could be provided by pharmacists across the spectrum of community pharmacy. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 is an evolutionary document that focuses on the provision of MTM services in settings where patients* or their caregivers can be actively involved in managing their medications. This service model was developed with the input of an advisory panel of pharmacy leaders representing diverse pharmacy practice settings (listed in Addendum). While adoption of this model is voluntary, it is important to note that this model is crafted to maximize both effectiveness and efficiency of MTM service delivery across pharmacy practice settings in an effort to improve continuity of care and patient outcomes. *In this document, the term patient refers to the patient, the caregiver, or other persons involved in the care of the patient.
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http://www.accp.com/docs/positions/misc/CoreElements.pdf

August 8, 2019

Multidimensional Geriatric Assessment: Back to the Future Early Effects of “Guided Care” on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial

Boult C, et al.Multidimensional Geriatric Assessment: Back to the Future Early Effects of “Guided Care” on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci.2008; 63 (3): 321-327.http://biomedgerontology.oxfordjournals.org/content/63/3/321.abstract. Accessed April 26, 2013.–Background. The quality of health care for older Americans […]
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Boult C, et al.Multidimensional Geriatric Assessment: Back to the Future Early Effects of “Guided Care” on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci.2008; 63 (3): 321-327.http://biomedgerontology.oxfordjournals.org/content/63/3/321.abstract. Accessed April 26, 2013.--Background. The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed “Guided Care” (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50–60 multimorbid older patients.
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http://biomedgerontology.oxfordjournals.org/content/63/3/321.abstract

August 8, 2019

Improving Transitions of Care: The Vision of the National Transitions of Care Coalition

The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient […]
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The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient safety while controlling costs.
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http://www.ntocc.org/Portals/0/PolicyPaper.pdf

August 8, 2019

Transitions of Care Performance Measures: Paper by the NTOCC Measures Work Group, 2008

The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality […]
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The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality of care transitions. The multi-disciplinary members of NTOCC work collaboratively to develop policies, tools, and resources as well as recommend actions and protocols to guide and support providers and patients in achieving safe and effective transitions of care.
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http://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf

August 8, 2019

Integrating Care for Populations and Communities

Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers […]
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Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers for Medicare & Medicaid Services (CMS) looks to QIOs to implement community-based projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.
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http://www.cfmc.org/integratingcare/

August 8, 2019

The Care Transitions Program

Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level […]
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Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; and influence health policy at the national leve
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http://www.caretransitions.org/